Your ability to put a drop on the eye every day means that you are
in charge of keeping your vision with glaucoma. But, as we’ll see, the
secrets of succeeding with drops are as much your head and your wallet as
they are in how well you do with the mechanics of eye drop taking. In the
next section, we’ll talk about the specific medicines now available as
glaucoma drops (Glaucoma eye drops: choices, choices)see section Glaucoma eye drops: choices, choices. Here, we’ll talk
about how to get the drop in your eye and how to remember to do it.

The dirty little secret of glaucoma drops (until recently) was
similar to what used to be a humorous description of the Soviet Russian
economy, where salaries were low and no one really did much work. The joke
by Soviet workers was: “I pretend to work and they pretend to pay me”. For
glaucoma, it was: “I pretend that I take all my drops and the doctor acts
like I take them all”. Twenty-five years ago, researchers put an early
computer in an eye drop bottle and found that patients were taking only 3
out of 4 of their drops—even when the bottles were handed out free.

Studies done in the last 5 years by our Wilmer Glaucoma Center of
Excellence have confirmed that little has changed. What we know is very
disturbing:

Of patients who are given a new prescription for glaucoma drops,
25% never fill the second one after getting their first bottle. They
had not stopped because the doctor had switched them to another
drop).

Of those who fill the second prescription, only half of all the
patients are still taking their drops regularly at the end of the
first year (Figure 20). This includes those
who switched or went on to surgery or something else.

Figure 20: Refilling Medications. A graph showing that many patients stop refilling
prescriptions for their glaucoma drops over time. By one year, less
than half were still on drops. Some types of drops had better
persistence with drop taking than others.

We gave our own patients free glaucoma drops and told them we were
going to monitor how many drops they took using an electronic counter on
their bottle that recorded when they took the drops. Even though we told
them we were keeping track of when they took the drops and urged them to
do their best to take them every day, the average patient took only 70% of
the drops. Amazingly, when we interviewed these folks and asked how many
drops they thought they were taking, they said they were taking 95% or
more. I know and respect these patients and I suspect that they believe
that they are taking all the drops. So it isn’t that they are lying to me.
Most of them just don’t know that they missed the drops—that’s why we call
it forgetting. Now with pills, if you have 31 pills to take in a month,
when you get to the end of the month and there are 5 pills left, you know
you screwed up. With eye drop bottles there’s no such clue. If you don’t
have an iron-clad reminder system, you will forget.

While it isn’t an excuse, patients taking pills for long term
diseases that have no symptoms (like high blood pressure) do just as badly
as glaucoma patients at remembering to take their meds. There’s only one
kind of chronic medication that does far better than this, where patients
take 100% of the pills on time. It’s the erectile dysfunction drugs (no
surprise there).

Some of our patients took only 20% of the drops. These folks with
big adherence problems have some characteristics we can identify. They may
have serious memory issues, such as dementia. They may not understand that
the drops must go in every day, which means there was a lack of
appropriate education. They may have a personality that allows them to
ignore that glaucoma can blind you. This is called denial. They do not
have a family member with glaucoma. They aren’t as likely to have taken
the time to find out about glaucoma. By reading this you’re marking
yourself as someone who is more likely to win by taking drops better.
Congratulations! But, if two or more of the statements above apply to you,
you may have more trouble remembering drops than you think.

Patients do best with drops right after the doctor visit, tail off
between visits, then start using them better again during the week coming
up to the visit. We all floss and brush our teeth like mad just before
seeing the dentist, so this behavior is understandable though unfortunate.
The secret to preventing vision loss is to be consistent and to take drops
every day in between visits. As we’ll see below, the key to making this
happen is to use memory aids that are as strong every day as that "just
before going to see the doctor" motivation.

One of the surprises of our studies was that we thought eye drop
side effects were a big cause of not taking drops properly. We found just
the opposite! Those who reported redness or stinging or blurring from
drops were more likely to be taking them. We should have realized that if
you’re not taking drops very often, you won’t have any side effects. Not
that the side effects are that bad—after all, those who reported some
minor side effects from drops were taking 9 out of 10 drops
dutifully.

So, how can we help patients do better with their drops? Our group
has done two big studies that show that effective memory aids work very
well. Those who were using only half of their drops improved dramatically
after we helped them to do a better job. We tried several ways to remind
them. First, we used an alarm that beeped when it was time for the drops.
Second, we used telephone calls, emails or text messages at the time that
they were supposed to take the drop. These simple efforts helped patients
succeed in controlling their glaucoma.

There are some simple memory aids that you can use to help you take
all the drops as prescribed. Nearly everyone now has a cell phone with an alarm feature. It can be set
to alarm every day or every 12 hours at eye drop time. There are "apps" that can be downloaded free that act as drug reminder alarms. Partners and spouses can
remind you to take drops. We call this acceptable nagging. A paper
calendar sheet and a pencil can be set next to the drop bottle as a low tech answer. Every time
the drop is taken an X is put on the paper. By checking at the end of
month, patients can see when they’re forgetting. An example is the patient
who found that no drops were getting in every Wednesday night. Wednesday
was bridge club night and she came home late and was missing the drops.
Anything that changes your usual daily routine will be likely to cause you
to forget your drops. This is especially true of travelling away from home.

Memory aids to remember drops

Link drop time to something else you always do

Alarm clock or cell phone alarm set for eye drop time

Spouse or family member who reminds you every day

Paper calendar sheet and pencil to record drop taking

Be careful to remember drops when away from home

Don’t hide the bottles in refrigerator or medicine
cabinet

It also matters what time of day the drops are supposed to be used.
Patients who plan to take drops every night at bedtime should not get into
bed and start reading or watching T.V. before their drops go in, because
they are likely to fall asleep and forget to take the drops. Make sure you
take the drop whenever you do something you always do, like taking a
morning pill, shaving, or putting the coffee pot on to brew. Out of sight,
out of mind: don’t put drops in the refrigerator or the medicine cabinet.
The prostaglandin drops do NOT need refrigeration despite misinformation still being given by some drug stores in their "information" sheets (see section Glaucoma eye drops: choices, choices).

The doctor should be part of the solution (and our studies show that
some doctors are part of the failure to achieve perfect drop taking). When
we studied the behavior of eye doctors with their glaucoma patients, we
found they could be grouped into 3 camps, which we called skeptics,
reactives, and idealists. The skeptics simply wrote the prescription for
drops and acted as if it was up to the patient to take it. When their
patients didn’t take drops well, they felt that there was nothing that
could be done. The reactive group of doctors was willing to try to help
patients with adherence with treatment when it was pretty obvious that
there was trouble. The final group is one that we hope will be emulated by
young doctors in training. These were the idealists—and actual data shows
that their patients take their drops better.

Idealist doctors realize that taking medicine is a shared activity
between doctor and patient. They establish a non-judgmental environment.
For example, they discuss with patients how hard it is to remember to take
every drop and agree that it is only human to forget sometimes. They ask
questions in an open-ended way that lets patients talk about the problems
that they’re having. They listen. The skeptic-type and reactive-type
doctors in our studies did most of the talking during video-taped study of
actual glaucoma visits. They asked closed questions like: “you’re taking
your drops, right?” for which patients would have to be pretty bold to say
“No”. Ideal doctors give patients a chance to tell them what they do and
don’t know about glaucoma. We did a study in which we asked veteran
glaucoma patients to tell us what the drops were intended to do.
Unfortunately, there were some who didn’t understand that drops lower eye
pressure and that lowering pressure stopped vision from getting worse. It
is too often that we hear: “I’m taking the drops, doctor, but my vision
doesn’t seem to be getting better”. That means we haven’t properly
educated our patients on how glaucoma treatment stops further damage, but
does not restore vision. Finally, ideal doctor behavior is to prescribe
only the amount of drops needed, and to keep it as simple as
possible.

It’s hard enough to remember to take the drops, but using the drops
effectively requires more thought than most people realize. Information
about drop-taking is unfortunately based on very little scientific data,
and pharmacies and drug companies (despite what should be the case) don’t
always help you to use the right amount of drug efficiently. If you sell a
product by the bottle, then having someone use it up as fast as possible
makes more money. To paraphrase Winston Churchill, capitalism is the worst
form of economic system, except for all the others. We don’t have to feel
sorry for drug companies and drug store chains—they’re making nice
profits. But, if you ever had drops come pouring out of a bottle as soon
as you began tipping it up toward your eye, you realize that the bottles
aren’t designed to be easy to use (at least some aren’t).

Here are the Lucky 13 ways you can get glaucoma eye drops into the
eye and not on the floor, while being effective at lowering eye pressure
(and saving money). (Figure 21, Figure 22)

Face the ceiling when putting drops in. Maybe teenagers can look
in a mirror, tilt their head way back and get a drop in the eye, but
for most of us, several drops wind up on the floor that way. Get
horizontal when taking drops, tilt your head way back while sitting in
a big comfy chair or better, lie flat in bed.

Brace the back of the hand with the bottle on your forehead
before tipping it up. We all have tremors and having the bottle waving
around without support hurts your aim.

Next, before you tilt the bottle over, look up to see that the
tip is over the nose half of your eye. Since you’re going to be
looking through the top of your head (see below) when the drop falls,
you can’t (and don’t want to) see it falling anyway. If any of the
drop falls on the area on the nose side of the eye, even if some hits
the edge of the eyelid or the inner corner, enough will get on the eye
surface to do the job. If you miss on the temple side, it’s likely to
treat the glaucoma in your ear, not your eye.

Pull down the lower eyelid of the eye with the hand that isn’t
holding the bottle. This increases the target on the white part of the
eye. As soon as the drop hits the eye, you can let go.

Let the bottle deliver as you tip it over and only squeeze if it
doesn’t come out by itself. This means that you will tip the bottle
over, above the nose side of the eye, and let it fall by gravity from
about 2 inches or less. Some bottles start having drops come out right
away. If the drop doesn’t come out by itself, squeeze gently until it
does.

Use only one drop per eye! Yes, I know that some bottles say put
in 2 drops (so does the information sheet from some drug stores).
That’s a huge waste. Each drop (which has from 25-50 microliters of
fluid) contains probably 5 times more drug than is needed for each
treatment. So even if you have 80% of it go somewhere else than on the
eye surface, you’re OK. Furthermore, using two drops gives you a
greater chance for bad effects on the rest of the body. When you put
medicine on the eye, it mixes with the tears, and this drains into the
nose through the lacrimal (tear) system in the corner of the eye near
the nose. That’s why you sometimes taste drops in your nose and throat
when you take them. It’s also why cocaine abusers snort drug up their
nose—it’s an effective method to get drugs into the body and head. The
same goes for eye drops, but with drops you want the least amount
anywhere else other than on the front of the eye.

As soon as you hit the eye with drop, close the eyelids and
don’t blink for 60 seconds. We’re now onto some pretty thin ice,
scientifically. There is some evidence that not blinking leaves the
drop on the eye longer—thus making it go into the eye more. But, when
we tested the actual pressure lowering with and without the don’t
blink instruction, it didn’t make a substantial difference. So it
makes sense not to blink, but we can’t say it has definitive
support.

Many doctors teach patients to push on the inner nose for 1
minute after putting the drop on the eye, to block the lacrimal drain
area and keep drops out of the nose, throat and the rest of the body.
Certainly, this naso-lacrimal occlusion makes logical sense, and there
is evidence that for children this can reduce the level of drug that
can be found in the blood stream after drops—which is a really good
idea if you are someone sensitive to the general body effects of
whichever drop you are using. However, very few of my patients are
doing nasolacrimal occlusion correctly when I ask them to show me
where they’re pushing. The fingers must be far back from the bridge of
the nose (almost poking the eye) and pushing almost hard enough to
hurt in order to stop drug from going to the nose.

After the drop hits and you close your eyes, some will be on the
skin of the eyelids. Blot off the excess, since some of us are
sensitive to it or may have an actual allergy to the drug or its
component parts. We don’t want to expose the skin daily to something
that may lead to itching, redness, and puffy lids. This requires
having facial tissues around before you start putting in drops.

You can treat one eye at a time, close, blot, push the nose, and
then treat the other eye in the same way. Or, if you’re a veteran and
can hit both eyes pretty quickly, you can do drop right, drop left and
close both, blot both, and push on both sides of the inner nose with
the thumb and forefinger for the 60 seconds. If you need to take more
than one kind of drop at that time of day, it’s faster to do both eyes
at once.

Wait between two types of drop on the same eye. Many glaucoma
patients need to use more than one drug to keep pressure at target.
They may have two or three bottles to put in, morning and evening. If
you put in drop 1 and in less than 60 seconds you put in drop 2, the
second one will wash away the first one and you’re not getting the
full effect of either one. Now the controversy: how long to wait
between bottles? I’ve heard doctors tell patients to wait 15 minutes!
This would mean that the person with 3 kinds of drops would need
half an hour to get the medicine in. There are no conclusive studies
of how long to wait. I suggest that the shortest possible time should
be 2 minutes, and if you have a system that lets you wait 5 minutes
it’s possibly better. However, humans being humans, I know that if you
put in drop 1, then say—I’ll just dry the dishes and come back for the
second drop, you’re more likely than not to forget to come back. Don’t
walk away until they’re all in.

If you’re using more than one type of drop, the order in which
they go in doesn’t matter.

Running out of medicine can be a big cause of non-adherence.
Many pharmacy plans give you either a 1 month or a 3 month supply of
drug. They don’t usually give you more than you need and typically it
is just barely enough if you use one drop at a time. The biggest cause
of running out of drug is using too much each time. Use one drop if
possible! A second cause for running out is not planning ahead. If
you’re going to the beach, you won’t forget the beach chairs, but an
astonishing number of people leave their eye drops at home. Most
doctors can fill a new bottle at the ocean-side drug store, but you’ll
probably pay full price for it. There is a third rule of drops,
namely, the bottle always runs out late on Friday night after the doctor’s
office is closed. Give things a shake on Thursday and see if you’re
going to need more. Fourth, the Food and Drug Administration (FDA)
puts an “expiration date” on drop bottles. This is something to look
for when the druggist gives you a 3 month supply—make sure they won’t
already have expired before the 3 months is up. Finally, a very
disturbing (but understandable) finding in one research project was
that needing to use a second eye drop type every day led some patients
to delay refilling the first bottle until they needed to get both
bottles filled. Some drops come as combinations of two types in one
bottle and this may help you with this problem.

Figure 22: More on Taking Eye Drops. The left drawing shows how to aim for the nose side of the eye
to help to get drops in with one drop only. This picture is drawn as
if looking down from the ceiling, since your face should be aimed at
the ceiling when doing drops properly (Figure 21). Right drawing illustrates where the
fingers are placed to do nasolacrimal occlusion to keep eye drops
from going into the nose, throat and rest of the body.

Take Home Points: 13 tips for taking eye drops
effectively

Face the ceiling

Brace the back of the hand with the bottle on your
forehead

Look up to see that the tip is over the nose half of your
eye

Pull down the lower eyelid

Let the bottle deliver by itself

Use only one drop per eye!

Don’t blink for 60 seconds

Push on the inner nose: nasolacrimal occlusion

Blot off the excess

You can treat one eye at a time

Wait between two types of drop

The order in which two drop types go in doesn’t matter

Running out can be a big cause of non-adherence

Some final aspects of drop taking. When asked to take them twice a
day, patients ask if it has to be exactly 12 hours apart. Ideally,
yes—but, practically, of course not. It’s good enough to hit it two times,
one early in the day and one late in the evening. Peg it to something you
do at each time, and when you finish the morning dose, and will take the
night dose at bedtime, move the bottle to where you’ll see it at night
(and back after the night dose to where you do the morning dose, if that’s
a different place). It is totally wrong, however, to take twice a day
drops at 9 am and 10 am. Space it out as close to 12 hours apart as much
as possible.

Some drops were approved by the FDA to be taken 3 times per day. In
desperate circumstances I ask patients to do this. They have to think up
elaborate schemes for how they’re going to take the bottles along wherever
they are and how to remember in the middle of a busy day to take them.
Generally, I’d rather think of a different way to manage their
glaucoma.

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